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Galen college of nursing NUR 155 exam 3 study set
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RN Tissue Integrity Assessment 2.0 Galen Nur 155 Exam 3 Galen college of nursing NUR 155 e... Ga
25 terms 336 terms 16 terms 33
beau_mendoza Preview alyssa_johnson978 Preview jessica_schoonmaker8 Preview
Terms in this set (573)
Characteristics of a stage 1 pressure ulcer A nonblanchable area with redness
Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
Characteristics of a stage 2 pressure ulcer Partial thickness with loss of skin including the epidermis and or dermis
Includes superficial wounds like cuts, blisters, or small open areas
Wound is painful
Ulcer is seen with reddish pinkish bed without slough or bruising
It's superficial and can appear as a blister, or shallow crater
Edema persists
Can become infected with pain and scant drainage
, Characteristics of a stage 3 pressure ulcer Full thickness skin loss
Injury extends through the dermis to the underlying fascia but does not extend
through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to be considered a
stage 3
Drainage and infection are common
Characteristics of a stage 4 pressure ulcer Has full thickness skin loss with visible muscle, tendon , and or bone present
Parts may be covered in slough or Eschar
Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the muscle , tendon , and
bone
Unstageable pressure ulcer characteristics When slough or eschar interferes with assessment of depth of pressure injury
and therefore staging is not possible
Characteristics of a suspected deep tissue injury Skin is intact
Patient had a purple or dark red or brown discoloration on the skin
Occurs when a pressure injury occurs underneath the skin so depth is unable to
be determined
Patient may have complained of pain in area before the discoloration occurred
The skin may have felt mushy , warm , or cool compared to surrounding areas
of skin
What are bony prominences? They are the end or a protrusion of bone where skin , muscle, and tissue is thin.
They are the highest risk areas of the body for developing pressure sores.
Full thickness injury An injury extending through the subcutaneous skin layers, muscles, and down
to the bone
What is blanching? It's whitening of the skin when pressure is applied. The result is brief temporary
loss of blood flow.
Note} pressure injuries and ulcers are non-blanchable.
Galen college of nursing NUR 155 exam 3 study set
Leave the first rating
Students also studied
Flashcard sets Study guides
RN Tissue Integrity Assessment 2.0 Galen Nur 155 Exam 3 Galen college of nursing NUR 155 e... Ga
25 terms 336 terms 16 terms 33
beau_mendoza Preview alyssa_johnson978 Preview jessica_schoonmaker8 Preview
Terms in this set (573)
Characteristics of a stage 1 pressure ulcer A nonblanchable area with redness
Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
Characteristics of a stage 2 pressure ulcer Partial thickness with loss of skin including the epidermis and or dermis
Includes superficial wounds like cuts, blisters, or small open areas
Wound is painful
Ulcer is seen with reddish pinkish bed without slough or bruising
It's superficial and can appear as a blister, or shallow crater
Edema persists
Can become infected with pain and scant drainage
, Characteristics of a stage 3 pressure ulcer Full thickness skin loss
Injury extends through the dermis to the underlying fascia but does not extend
through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to be considered a
stage 3
Drainage and infection are common
Characteristics of a stage 4 pressure ulcer Has full thickness skin loss with visible muscle, tendon , and or bone present
Parts may be covered in slough or Eschar
Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the muscle , tendon , and
bone
Unstageable pressure ulcer characteristics When slough or eschar interferes with assessment of depth of pressure injury
and therefore staging is not possible
Characteristics of a suspected deep tissue injury Skin is intact
Patient had a purple or dark red or brown discoloration on the skin
Occurs when a pressure injury occurs underneath the skin so depth is unable to
be determined
Patient may have complained of pain in area before the discoloration occurred
The skin may have felt mushy , warm , or cool compared to surrounding areas
of skin
What are bony prominences? They are the end or a protrusion of bone where skin , muscle, and tissue is thin.
They are the highest risk areas of the body for developing pressure sores.
Full thickness injury An injury extending through the subcutaneous skin layers, muscles, and down
to the bone
What is blanching? It's whitening of the skin when pressure is applied. The result is brief temporary
loss of blood flow.
Note} pressure injuries and ulcers are non-blanchable.
